Gynecology Focused Note Student Name Master of Science in Nursing, Walden University PRAC 6552: Advanced Nurse Practice in Reproductive Health Care Date Gynecology Focused Note Patient Information: Patient Initials: E.W. Age: 54 Gender: Female Race: White Subjective Data: CC: HPI: 54-year-old white female presents to clinic for a well woman’s exam. Patient states she has a new boyfriend and is having pain during intercourse. Patient reports the pain during sex feels like a lot of pressure and sometimes burns. She states she also has been having issues with frequent urination. She has been taking her oxybutynin to help with peeing so much with little to no relief. She rates her pain during intercourse a 5/10. Entered menopause at age 51. Current Medications: 1)Oxybutynin 5mg PO TID 2)ProAir HFA 90 mcg/inh inhalation aerosol, 2 puffs QID prn coughing/shortness of breath 3)Spiriva 18mcg INH daily Allergies: 1.) NKA Past Medical History (PMH): 1.) HTN 2.) COPD Past Surgical History (PSH): 1.) Denies any previous surgeries. Personal/Social History: Alcohol Use: Denies Tobacco/Nicotine Usage: Former smoker, quit in 1999 Recreational Drug Use: Denies Significant Family History: 1.DM II 2.HTN 3.Thyroid disease 4.HLD Immunization History: Immunizations UTD, Tdap 11/29/2020, Influenza Vaccine 11/29/2020, COVID-19 Vaccine 1/29/2021, 3/4/2021 Lifestyle: Patient lives at home alone; in town in a low crime area; financially stable with medical insurance. Patient has a good support system of boyfriend and children. Gynecology: Last pap smear 2016, last MMG 2016. Menstrual history: menses started at age 13. Menopause at age 51. Obstetrics: G2P2, Vaginal deliveries 2, C-section 0. Two daugh......... Continue